Analysis Bank Suction and Vessel Manoeuvring Five minutes before the collision, the JoSpirit was already very close to the channel's north bank and experiencing increased bank suction aft. More and more starboard helm was therefore necessary to maintain the required heading. Although the high side forces generated by the Becker rudder could counteract the increasing bank suction, they also allowed the situation to persist. As soon as the rudder was placed amidships, however, the counteracting forces generated by the rudder were lost and the vessel sheered to port. According to data obtained from the AIS, the Orla crossed the channel's centreline and moved to the north side at some time before the collision. This is consistent with the observation of the pilot of the JoSpirit that the Orla was crowding the north side of the channel. Given moulded breadths of 15.9m and 23m, respectively, the JoSpirit and Orla would take up much of the available manoeuvring space in a channel only 70m wide. Figure4 shows a meeting between these two vessels in which maximum even space is maintained between the vessels, and also between each vessel and the channel bank. Even in this ideal case, however, only approximately 10m would exist between the vessels and between each vessel and the bank- a tight fit given the size of the vessels. Figure4.Vessel template to scale with the channel bank profile Communication between Pilots The conduct of vessels in narrow channels, which is governed by the International Regulations for Preventing Collisions at Sea, 1972, requires that each vessel keep, as far as is safe and practical, to the starboard side of the channel.13 However, it is the accepted practice when meeting in very narrow channels that both vessels "stand on" near mid-channel for as long as possible before each alters to starboard. This is common practice in the South Shore Canal and not only allows the vessels to benefit from the bow cushion effect as they meet, but reduces the incidence of bank suction at the stern before the meeting. In this instance, the Orla was crowding the manoeuvring space of the JoSpirit before the collision and influenced the pilot of the JoSpirit to move farther to the north side of the channel, and at an earlier time than desirable. However, he did not communicate these concerns to either the bridge team or the pilot of the Orla. The pilots had been in communication, but discussed non-navigational matters. Night Navigation in the South Shore Canal Night navigation within the South Shore Canal is primarily dependent on visual cues taken from lights mounted on wooden lampposts on either side of the channel (see Photo4). Above Cte-Sainte-Catherine lock, many lights were extinguished, and had been for some time. Others were obstructed by trees and bushes, a situation that reduces the spatial orientation of the bridge team. The reduced shore-side lighting, therefore, may have hampered the ability of the pilots of both vessels to accurately assess their respective vessel's position within the channel in the minutes leading up to the collision. Furthermore, a ship's radar is unable to give accurate information with respect to distances off canal banks in narrow channels and, if there is no other system (such as an ECS) aboard, greater reliance must be placed on the shore aids and visual cues - in this case, the lamppost lights and the visual observation of the canal bank. The Orla was not fitted with an ECS and the pilot, relying on visual aids, believed the vessel to be in the centre of the channel, whereas it was actually north of the centreline and closing toward the north bank. The St. Lawrence Seaway is an important North American transportation infrastructure. Given the very small margin of error for vessels meeting in this location, and with the potential for serious consequences in the event of an accident, visual night navigation in this sector of the Seaway is dependent upon the sufficiency, reliability, and adequate maintenance of lamppost-mounted lights and their visibility from both channel directions. Bridge Resource Management Successful BRM requires full and complete communication among the team so that all members share the same mental model and have a common understanding of the situation. Using command/order confirmation is an effective way to achieve this. When communication is less than adequate, the efficacy of the bridge team is reduced and risks increase. During the several minutes preceding the sheer to port, increasing amounts of starboard helm were applied to steer the JoSpirit parallel to the channel and counteract the bank suction effect. Given the high efficiency of a Becker rudder, using 30, 20, or even 10 of helm to steer a straight course is an unusual requirement. Nonetheless, neither the helmsman nor the OOW, who were closely monitoring the situation, communicated to the pilot the amount of helm action being used. The pilot of the JoSpirit was not closely monitoring the rudder angle indicator and was not aware that excessive helm was being used to maintain the vessel's heading. Furthermore, there is conflicting information regarding the amidships helm order that precipitated the sheer to port. Effective BRM could have ensured that the bridge team on the JoSpirit had a common understanding of the situation. Instead, the pilot was operating in isolation, and an opportunity to take remedial measures was lost. Given the tight fit in the channel, inter-ship communication was critical, particularly as inadequate shore-side lighting may have reduced visual cues. In this instance, although he believed correctly that the Orla was over the channel's centreline, the pilot of the JoSpirit did not confirm this with the Orla's pilot. The pilots had been in communication, but were discussing non-navigational matters. The Orla was navigating to the north of the centre of the channel, and the pilot of the JoSpirit reacted by moving closer to the north bank of the channel to allow more manoeuvring room. The bank suction effect on the JoSpirit became progressively pronounced, requiring increasing starboard helm; the placing of the helm to amidships caused the vessel to sheer to port. There was no relevant communication between the pilots of the two vessels throughout the developing situation. Ineffective bridge resource management (BRM) aboard the JoSpirit resulted in critical information not being shared with the pilot, thus precluding timely action. Inadequate shore-side lighting, combined with the overgrowth of trees and bushes, may have hampered the ability of both pilots to accurately assess their respective vessel's position within the channel.Findings as to Causes and Contributing Factors The Orla was navigating to the north of the centre of the channel, and the pilot of the JoSpirit reacted by moving closer to the north bank of the channel to allow more manoeuvring room. The bank suction effect on the JoSpirit became progressively pronounced, requiring increasing starboard helm; the placing of the helm to amidships caused the vessel to sheer to port. There was no relevant communication between the pilots of the two vessels throughout the developing situation. Ineffective bridge resource management (BRM) aboard the JoSpirit resulted in critical information not being shared with the pilot, thus precluding timely action. Inadequate shore-side lighting, combined with the overgrowth of trees and bushes, may have hampered the ability of both pilots to accurately assess their respective vessel's position within the channel. The controllable-pitch control unit of the JoSpirit was offset such that, at the zero pitch setting, the vessel would continue to make headway. Although the JoSpirit's helm indicator was graduated to the full 60 of rudder angle, the rudder angle recorder was only graduated to a maximum of 45. Starboard bow thrust was reportedly requested by the pilot of the JoSpirit when the JoSpirit sheered to port, but was not applied. It is unlikely, however, that the application of the bow thruster at this time would have changed the outcome of this occurrence.Other Findings The controllable-pitch control unit of the JoSpirit was offset such that, at the zero pitch setting, the vessel would continue to make headway. Although the JoSpirit's helm indicator was graduated to the full 60 of rudder angle, the rudder angle recorder was only graduated to a maximum of 45. Starboard bow thrust was reportedly requested by the pilot of the JoSpirit when the JoSpirit sheered to port, but was not applied. It is unlikely, however, that the application of the bow thruster at this time would have changed the outcome of this occurrence. Safety Action Action Taken Transportation Safety Board of Canada On 03 August 2005, Marine Safety Information Letter01/05, Vessels Meeting in Restricted Channels, was sent to the Great Lakes Pilotage Authority to inform it of the facts concerning the occurrence and to reiterate the importance of vessels adhering to standard meeting procedures. On 14 October 2005, Marine Safety Information Letter 04/05, Less Than Adequate Visual Aids for Night Navigation in the South Shore Canal, was sent to the St. Lawrence Seaway Management Corporation (SLMC). The letter brought attention to the numerous non-functioning lights reported on the south side of the channel above Cte-Sainte-Catherine, as well as the growth of trees and shrubs that reduces the visibility of functioning lights. In response, the SLMC advised that work was completed by 31October2005 on bank lighting circuits7, 8,and 10,as well as brushing and tree trimming along the channel above Cte-Sainte-Catherine lock, to improve the quality of visual aids for night navigation. Work on circuit9 was completed in2006. Additionally, the SLMC has stated that the corporation will improve its water-side inspections to better target its tree-trimming/cutting program and thus ensure proper visibility of the canal bank sides and lights from vessels at night. Jo Tankers AS, Norway Following the occurrence, the company conducted an in-house investigation. A new familiarization task was added to the checklist for deck officers and helmsmen. An information binder on the rudder and its performance characteristics was compiled and is now kept in the wheelhouse. Additionally, a small working model of the Becker rudder is mounted in the wheelhouse to demonstrate functionality. Helmsmen are now instructed to put the rudder to 35 when "hard over" helm is requested (since maximum side thrust is achieved at this angle). If, during manoeuvring at slow speeds, rudder angles of 60 are needed so the rudder can act as a stern thruster, the order "full helm" is to be used. The company also conducted refresher bridge resource management (BRM) training for all officers using the collision case of the JoSpirit as a model with a focus on intervention and challenging pilot's action. Polska Zegluga Morska, Poland In response to the occurrence, an internal investigation was held and the conclusions were shared with the company's masters. Relevant procedures within the safety management system were amended and implemented. Great Lakes Pilotage Authority Through the use of a marine navigation simulator, the Great Lakes Pilotage Authority has instituted training exercises for its pilots of vessels meeting in the South Shore Canal at night.